Fillable Recredentialing Application Institution/Facility (Blue Cross Blue Shield of North Dakota)

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Recredentialing Application Institution/Facility (Blue Cross Blue Shield of North Dakota)

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The Recredentialing Application Institution/Facility (Blue Cross Blue Shield of North Dakota) form is 2 pages long and contains:

  • 1 signature
  • 22 check-boxes
  • 63 other fields

Country of origin: US
File type: PDF

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Page 1 of 3
29380178 • 2-21
Recredentialing Application
Institution/Facility
Recredentialing is conducted every three years and unless you are notied, your participation will remain eective with no gaps.
Facility/Agency Type
Place a check next to ALL correct classications
Ambulatory Surgery Center
Diabetes Prevention Program
Dialysis/Kidney Center
Free Standing Radiology/Portable X-Ray Supplier
General Hospital (Short Term)
General Hospital (Long Term)
Hearing Aid Supplier
Home Health Agency
Hospice
Laboratory (Independent or Hospital-Based)
Rehabilitation Facility
Skilled Nursing Facility
Swing Bed
Urgent Care
Other (Description):
Institution or Facility Information
Please complete a separate application for each practicing location
Name of Facility:
NPI:
Taxonomy Code:
Federal TIN:
Eective Date of Group:
Display in Directory
Yes No
Physical Street Address (Street, City, State, ZIP):
Street
City State ZIP
Billing/Mailing Address (Street, City, State, Zip)
(If dierent from Physical address):
Street
City State ZIP
Patient Appointment Phone #:
( )
Oce Fax #:
( )
Billing Phone #:
( )
Billing Fax #:
( )
Oce Sta Foreign Languages:
Speak Read Write N/A
Business Oce Contact Name:
Business Oce Email Address:
Is the Facility Certied as a National Disaster Medical System
(NDMS)?
Yes No
Name and Title of Chief Administrator:
Total Licensed Bed Capacity: Facility Accepts (Check All That Apply):
Credit Card Debit Card Neither
Trauma level
I – All Complex Injuries
II – Severe Trauma
III – Common Trauma w/o specialized care
IV – Routine Care
V – Routine Care – May not be 24/7
0 – No Trauma Care
Page 2 of 3
29380178 • 2-21
Current License/Certicate
Attach A Current Copy Of All Licenses And Certicates That Apply
Issued By
Current State License
Or Certication #
Original Issue Date Expiration Date
State
Medicare Certication #
Medicaid
The Joint Commission
CARF
(Commission On Accreditation of
Rehabilitation Facilities)
AAAASF
(American Association for
Accreditation of Ambulatory Surgery
Facilities)
AAAHC
(Accreditation Assoc. for Ambulatory
Health Care, Inc.)
Other
Malpractice/Liability Insurance
Attach a copy of malpractice insurance face sheet
Release and Attestation
The undersigned is authorized to act on behalf of the institution/facility (Entity), and certies that all information submitted on this
application and all attachments hereto are correct, true and complete to the best of my knowledge.
The Entity consents to complete disclosure of and authorization to make available to Blue Cross Blue Shield of North Dakota
(BCBSND), its aliates or any of their agents, all relevant information pertaining to and deemed necessary and appropriate in the
investigation and processing of this application, including but not limited to, information obtained through a third party such as an
insurance company, licensing authority, accrediting agency or governmental agency.
The Entity releases and discharges BCBSND, its aliates and their representatives, credentials committees, administrators,
governing bodies, agents, employees and all other persons or entities supplying information to them, from liability or claims of
any kind or character in any way arising out of inquiries or disclosures made in good faith in connection with this application.
The Entity agrees to update this application while it is being processed should there be any change in the information provided
regarding the Entity that could aect the application or its outcome. A photocopy of this document shall be as eective as
the original.
Name (print or type) Title
Signature Date (MM/DD/YYYY)
SUBMIT
SUBMIT FORM
click to sign
signature
click to edit
Page 3 of 3
29380178 • 2-21
SUBMIT INSTRUCTIONS
If you are having diculty submitting the form once completed, please send using one of the following methods:
• Email (Please follow these steps):
- Click on ‘File’ at the top of your screen
- Click on ‘Save As’
- Save the completed form on your computer
- Attach the completed form to an email and send to providerforms@bcbsnd.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave S
Fargo, ND 58121
Double check that the application is complete!
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Recredentialing Application InstitutionFacility (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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